RMH Patient Survey

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Patient Survey

Instructions: Please fill in the background questions, then rate the services you received while in Ransom Memorial Hospital. Choose the number that best describes your experience. If you did not receive a service, skip to the next question. Space is provided for you to comment on good or bad things that may have happened to you. When you have completed the survey, please submit by clicking on the submit button below. We thank you for taking the time to fill out the survey.

Background Questions

1. Was this your first stay here? Yes No

2. Were you admitted through the Emergency Room? Yes No

3. Was your admission unexpected? Yes No

4. Did you have a roommate? Yes No

5. Were you placed on a special or restricted diet during most of your stay? Yes No

6. Did someone explain your extended life support (living will) options? Yes No

7. Did someone give you information about organ donation? Yes No

8. Did someone give you information about the Patient's Bill of rights? Yes No

9. Do you have insurance that limits your choice of physician or provider (e.g. HMO, PPO)? Yes No

10. Main source of payment for hospital stay (choose only 1)
Private Insurance Medicare Medicaid Worker's Compensation Self Pay

11. Room Number

12. Days in hospital

13. Date of discharge mm/dd/year

14. Patient's sex Male Female

15. Patient's age

16. Compared to others your age, would you typically describe your health as:
Very Poor Poor Fair Good Very Good

17. Your name? (optional)

18. Phone Number? (optional)

A. Admission

Very
Poor

Poor

Fair

Good

Very
Good

1. Speed of the admission process

2. Courtesy of the person who admitted you

3. Rating of pre-admission process (if any)

Comments concerning admission: (describe good or bad experiences):

B. Room

Very
Poor

Poor

Fair

Good

Very
Good

1. Pleasantness of room decor

2. Room cleanliness

3. Courtesy of the person who cleaned your room

4. Room temperature

5. Noise level in and around room

6. How well things worked (TV, call button, lights, bed, etc.)

Comments concerning the room: (describe good or bad experiences):

C. Meals

Very
Poor

Poor

Fair

Good

Very
Good

1. If you were placed on a special/restricted diet, how well was it explained

2. Temperature of the food (cold foods cold, hot foods hot)

3. Quality of the food

4. Courtesy of the person who served your food

Comments concerning meals: (describe good or bad experiences):

D. Nurses

Very
Poor

Poor

Fair

Good

Very
Good

1. Friendliness/courtesy of the nurses

2. Promptness in responding to the call button

3. Nurses' attitude toward your requests

4. Amount of attention paid to your special or personal needs

5. How well the nurses kept you informed

6. Skill of the nurses

Comments concerning Nurses: (describe good or bad experiences):

E. Tests and Treatments

Very
Poor

Poor

Fair

Good

Very
Good

1. Waiting time for tests or treatments

2. Concern shown for your comfort during tests or treatments

3. Explanations about what would happen during tests or treatments

4. Skill of the person who took your blood (e.g. did it quickly, with minimal pain)

5. Courtesy of the person who took your blood

6. Skill of the person who started the IV (e.g. did it quickly, with minimal pain)

7. Courtesy of the person who started the IV

Comments concerning tests and treatments: (describe good or bad experiences):

F. Vistors and Family

Very
Poor

Poor

Fair

Good

Very
Good

1. Helpfulness of the people at the information desk

2. Accommodations and comfort for visitors

3. Staff attitude toward your visitors

4. Information given to your family about your condition and treatment

Comments concerning vistors and family: (describe good or bad experiences):

G. Physician

Very
Poor

Poor

Fair

Good

Very
Good

1. Time physician spent with you

2. Physician's concern for your questions and worries

3. How well physician kept you informed

4. Friendliness/courtesy of physician

5. Skill of physician

Comments concerning physician: (describe good or bad experiences):

H. Discharge

Very
Poor

Poor

Fair

Good

Very
Good

1. Extent to which you felt ready to be discharged

2. Speed of discharge process after you were told you could go home

3. Instructions given about how to care for yourself at home

4. Help with arranging home care services (if needed)

Comments concerning discharge: (describe good or bad experiences):

I. Personal Issues

Very
Poor

Poor

Fair

Good

Very
Good

1. Staff concern for your privacy

2. Staff sensitivity to the inconvenience that health problems
and hospitalization can cause.

3. How well your pain was controlled

4. Degree to which hospital staff addressed your emotional/
spiritual needs

5. Response to concerns/complaints made during your stay

6. Staff effort to include you in decisions about your treatment

Comments concerning personal issues: (describe good or bad experiences):

J. Overall Assessment of Hospital

Very
Poor

Poor

Fair

Good

Very
Good

1. Overall cheerfulness of the hospital

2. How well staff worked together to care for you

3. Likelihood of your recommending this hospital to others

4. Overall rating of care given at hospital

Comments concerning overall assessment of hospital: (describe good or bad experiences):

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